Complaint·May 10, 2024

LPA Dolores interviewed a staff member (S1) and it was mentioned that when they we redoing the assessment for R1, RP didn’t allow the staff to check R1s skin. RP told there’s no pressure injury and R1 has redness on the bottom but it’s okay. Upon moving in, the Health Services Director (HSD) wasn’t here. They weren't able to do the skin check upon move in day. It was reported later that there was a tiny opening of .5 cm. HSD checked it and reported it to RP, doctor, and requested home health when they found out there was an opening. There is a PRN cream that needs to be applied. Normal procedure is to do a skin check prior to move in but RP was saying no need to because R1 doesn’t have any issues. That’s the only one that they didn’t do the skin check for. Another staff member, S5, mentioned that R1 has some type of pressure injury and it was not staged. During the pre-assessment there was redness but didn’t check R1s skin. Family didn’t let them check the skin. LPA Donato was able to interview the Home Health Nurse and it was confirmed that the pressure injury was at stage two. Based on records review, a charting report showed that on 12/16/2023 input by S6 at 9:30PM that R1 had a blister on left heel and Tylenol was given for pain and discomfort. Regarding the allegation of staff did not administer resident's medication, RP stated that R1 has butt paste to prevent R1 from getting pressure sores and the staff haven’t been putting it on. LPA Donato reviewed the Medication Administration Records (MAR) of R1, and it shows that the cream that was prescribed as needed (PRN) and had a direction of being applied topically each bowel movement/diaper change was not done regularly. MAR from October 19-31 2023 showed the cream was only applied for seven random days. MAR from November 2023 also showed cream being applied three to four random days. ...PAGE 2 of 4 LPA Donato did a records review and facility was able to provide documentation for in service training regarding Resident Fall Management, Proper Positioning, Bowel Protocol and annual trainings for Dementia Care-Performing ADLs (Activities of Daily Living) and Assisting with ADLs. Based on interviews and records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. ...PAGE 2 of 2 Regarding the allegations of staff left resident in soiled diapers for an extended period of time and Staff are not meeting resident’s needs, RP stated that R1 is not being changed enough and ends up with soaked diapers and clothing. RP stated that the staff have even put double diapers on R1 to get out of changing her. Based on records review, a photo evidence was submitted by RP showing a soiled double diaper that was removed from the resident. On R1s individualized service plan dated 10/16/23, it is noted that R1 takes a medication which makes R1 urinate a large amount up to six hours after the first dose so R1 needs to go frequently to toilet. An document was obtained acknowledging that RP addressed the double diapers to the facility and that facility acknowledged this and stated that it will address the situation. LPA Dolores interviewed five staff members. S2 mentioned that he/she doesn’t know of any soiled diapers. S3 stated that R1 is not left for a long time and changes R1s diaper as soon as needed. Regarding the allegation of facility does not have adequate staff in memory care to meet the resident’s needs, RP stated that there is not enough staff to handle the residents in memory care. Based on records review, the month of October 2023 there are three to four caregivers scheduled per shift and this does not include the med tech. Shift times start at 6am to 2pm, 2pm to 10pm and NOC shift, 10pm to 6am has 2 staff scheduled. During the interview, S2 mentioned that they are not short staffed in memory care. S2 has seven residents under his/her care. S3 stated that they normally have the same groups of residents and currently has six in the group. S4 stated that there are usually three caregivers. On Wednesday and Thursdays there are four. S4 is the extra and they have enough staff to care for the residents. S4 also mentioned that there are three caregivers on the floor and med tech steps in. Ratio is one caregiver is to six or seven residents. Time management is very important, so they can meet their needs. ...PAGE 3 of 4 However, S3 also mentioned that R1 needs a diaper change about four to five times during the shift. R1 also is not able to go to the bathroom unassisted. S5 also mentioned that R1s toileting happens every two hours. R1 has diaper changes around four to five times and during night shift will be two to three times. Based on interviews, records review and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. A deficiency was cited during today’s visit, see LIC809-D. A civil penalty for repeat violation within the 12-month period is being assessed for the amount of $250, see LIC421FC. Additional civil penalties are pending review. A copy of this report and the Appeal Rights are provided. ...PAGE 4 of 4